PETERSBURG PHARMACY INC NPI 1538259403

NPI Information

  • NPI: 1538259403
  • Provider Name: PETERSBURG PHARMACY, INC
  • Classification: Pharmacy - 3336C0003X
  • Specialization: Community/Retail Pharmacy
  • Entity Type: Organization
  • CLIA Number: 14D2202682
  • Address: 1 CENTRE DR
    SUITE 100
    PETERSBURG, IL
    ZIP 62675
  • Phone: (217) 632-7777

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NPI Details

PETERSBURG PHARMACY, INC is a community/retail pharmacy pharmacy in Petersburg, IL. The provider is a pharmacy where pharmacists store, prepare, and dispense medicinal preparations and/or prescriptions for a local patient population in accordance with federal and state law; counsel patients and caregivers (sometimes independent of the dispensing process); administer vaccinations; and provide other professional services associated with pharmaceutical care such as health screenings, consultative services with other health care providers, collaborative practice, disease state management, and education classes. PETERSBURG PHARMACY, INC NPI is 1538259403. The provider is registered as an organization entity type.

The provider's business location address is:

1 CENTRE DR
SUITE 100
PETERSBURG, IL
ZIP 62675-467
Phone: (217) 632-7777
Fax: (217) 632-7618

The provider's authorized official is David Bagot .
The authorized official title is Pharmacist/owner and has the following contact phone number (217) 632-7777.

The CLIA number assigned to this NPI record is 14D2202682 - pharmacy with a certificate type of Certificate of Waiver.

The following top HCPCS codes were publicly reported for this provider under the Medicare program for the year 2016. The reported codes are based on the top codes for each available Medicare specialty, excluding evaluation and management codes.

  • Administration of influenza virus vaccine (HCPCS:G0008)
  • Influenza vaccine, quadrivalent inactivated, 0.5 ml dosage (HCPCS:90694)
  • Fee covid-19 vac 14 res (HCPCS:0134A)
  • Adm sarscov2 50mcg/0.25mlbst (HCPCS:0064A)
  • Fee covid-19 vac 13 res (HCPCS:0124A)
  • Adm sarscov2 30mcg/0.3ml bst (HCPCS:0004A)
  • Adm sarscov2 100mcg/0.5ml3rd (HCPCS:0013A)
  • Adm sarscov2 30mcg/0.3ml 3rd (HCPCS:0003A)

The enumeration date for this NPI number is 10/13/2006 and was last updated on 6/2/2015.

Taxonomy Codes

The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:

No. Taxonomy Code Taxonomy Clasification Taxonomy Specialization License Number License State Primary
13336C0003XPharmacyCommunity/Retail Pharmacy054.015430ILLINOISYes

Other Identifiers

The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.

No. Other Provider Identifier Other Provider Identifier Type Other Provider Identifier State Other Provider Identifier Issuer
13574-5932OTHERILLINOISSTATE ID NUMBER
2054.015430OTHERILLINOISDIV 1 PHARMACY LICENSE
3=========001MEDICAIDILLINOIS
4120007769OTHERILLINOISMEDCO PROVIDER NUMBER
51477745OTHERILLINOISNABP NUMBER
6320.008365OTHERILLINOISCONTROLLED SUB LIC #
75385570001MEDICARE ID-TYPE UNSPECIFIEDILLINOISMEDICARE PROVIDER NUMBER

What is NPI?

NPI stands for National Provider Identifier. The NPI is a 10-digit identification number that is completely unique. The NPI number by itself does not contain any identifiable information such as a provider’s speciality or location. The NPI is assigned to individuals or organizacions for their lifespan and it is independent of key provider information type updates like a change of practices, location or speciality.

This page was last updated on: 11/21/2025

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